Assessment Initiating the Interview.docx - Initiating the...

Initiating the Interview
Nurse Information
 Patient name
 Age
 Reason for visit
 Height and Weight; sometimes BMI
 Blood pressure, Pulse, Temp
Clinician Activities
1. Announce yourself before entering the room
 knock and ask if the patient is ready for you to enter
2. Introduce yourself
3. Confirm the identity of your patient and ask how they would like you to
referred to them
4. Disinfect your hands
5. Cover the patient and make yourself comfortable for a conversation with the
patient
Comprehensive History Overview
Structure of Comprehensive History: 7 components
1. Identifying Data
2. Chief Complaint
3. History of Present Illness
4. Past Medical History
5. Family History
6. Personal and Social History
7. Review of Systems
Identifying Data (ID)
 Name of patient
 Age of patient
 Gender of patient
 Location of visit
 Reliability of person providing the information

Chief Complaint (CC)
 Description of what brought the patient to seek medical attention
